Healthcare Provider Details

I. General information

NPI: 1467500470
Provider Name (Legal Business Name): MARIA MARISSA DE LEON LIWAG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA MARISSA ANUDDIN DE LEON-LIWAG M.D

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 BANGS AVE
MODESTO CA
95356-8713
US

IV. Provider business mailing address

4125 BANGS AVE
MODESTO CA
95356-8713
US

V. Phone/Fax

Practice location:
  • Phone: 209-551-3174
  • Fax: 209-557-1685
Mailing address:
  • Phone: 209-551-3174
  • Fax: 209-557-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA89974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: